What's behind the Data: An Examination of the Processes and Policies Underlying the Routine Collection of Clinical Data in Ontario Hospitals

Abstract

This article surveyed the processes and policies underlying the routine collection of clinical data in acute care hospitals in Ontario, Canada. Although there is evidence of a small shortfall in the availability of human resources, most health records departments employ experienced staff with health records certification. However, there is much more important variation in the documented and undocumented processes used to generate routinely collected clinical data. Current guidelines and coding schedules are helpful but insufficient to guide the production of good quality data. The variations in the processes used to produce clinical data have important implications for the management, reimbursement, and planning of healthcare. This is particularly critical at a time when hospitals and other stakeholders, such as governments, are relying more and more on accurate, reliable, and comparable data.

Get full access to this article

View all access options for this article.

References

Boscarino

J.A.

and Chang

(1997). “Commentary: Inaccurate Data on the Quality of Care May do More Harm than Good—An Alternative Approach Is Required.” American Journal of Medical Quality 12: 196–200.

Canadian Centre for Health Information NRC (1993). Canadian Classification of Diagnostic, Therapeutic, and Surgical Procedures, 2nd ed. Ottawa: Statistics Canada.

Canadian Centre for Health Information NRC (1997), Canadian Coding Source Book. Ottawa: Author.

Goldberg

M.J.

(1981). “Hospital Inpatient Statistics: Some Aspects of Interpretation.” Community Medicine 3:60–68.

Huston

and Naylor

CD.

(1996). “Health Services Research: Reporting on Studies Using Secondary Data Sources.” Canadian Medical Association Journal 155:1697–1702.

Iron

and Williams

(1996). Appendix 1. “A Summary of Studies on the Quality of Health Care Administration Databases in Canada,” in Goel

(ed.). Patterns of Health Care in Ontario: ICES Practice Atlas, 2nd ed. Toronto: Institute for Clinical Evaluation Sciences in Ontario.

Simborg

D.W.

(1981) “DRG Creep: A New Hospital-Acquired Disease.” New England Journal of Medicine 304:339–345.

J.V.

. (2001). “Problems for Clinical Judgment 4: Surviving in the Report Card Era.” Canadian Medical Association Journal 164:1709–1712.

United States National Center for Heath Statistics (1987). Annotated International Classification of Diseases, 9th Revision, Clinical Modification. Ann Arbor: Edward Brothers.